Healthcare Provider Details

I. General information

NPI: 1871773101
Provider Name (Legal Business Name): INGRID H PARK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2007
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 NORIEGA ST # 77
SAN FRANCISCO CA
94122-4239
US

IV. Provider business mailing address

2309 NORIEGA ST # 77
SAN FRANCISCO CA
94122-4239
US

V. Phone/Fax

Practice location:
  • Phone: 628-233-2646
  • Fax:
Mailing address:
  • Phone: 415-948-0380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: